護理師照護一位髖關節置換術後病人，下列哪項評估結果需要立即採取護理措施？
A nurse is caring for a client who is postoperative following a total hip arthroplasty. Which assessment finding requires immediate nursing intervention?
- ACapillary refill of 3 seconds in the affected toes患側腳趾的微血管回流時間為 3 秒
- BSerosanguinous drainage on the dressing敷料上有漿血性滲出物
- CInability to dorsiflex the foot on the affected side✓ 正解患側足部無法背屈
- DPain level of 4/10 upon movement活動時疼痛程度為 4/10
神經血管完整性是術後護理的最高優先級。髖關節置換術後，病人出現無法背屈（dorsiflexion）腳踝的現象，高度提示腓總神經受壓或受損，這是神經損傷的早期指標，若不緊急處理可能造成永久性的足下垂（foot drop）。這與術後正常的出血滲液或輕微疼痛不同，神經損傷屬於不可逆的嚴重併發症，必須立即通知醫師評估術後敷料是否過緊、患肢擺放是否導致神經牽拉或發生腔室症候群。護理師應評估患肢的神經血管狀態（CMS），並對比健側，確保不會錯失黃金救援時間。
Neurovascular integrity is the highest priority in postoperative care. After a total hip arthroplasty, inability to dorsiflex the foot strongly suggests peroneal nerve compression or injury, an early indicator of neurological damage that, if not addressed urgently, may cause permanent foot drop. Unlike normal postoperative drainage or mild pain, nerve injury is an irreversible serious complication that requires immediate notification of the provider to evaluate whether the dressing is too tight, the limb is positioned in a way that stretches the nerve, or compartment syndrome is developing. The nurse should assess the affected limb's circulation, motion, and sensation (CMS), compare with the unaffected side, and ensure that the window for intervention is not missed.
美國護理師在面對此類神經損傷徵兆時，通常會啟動標準骨科術後神經評估路徑（neurovascular checks protocol）；台灣護理師執行時，除了回報醫師，更常會立即檢查彈性繃帶是否過緊，並在記錄中詳細描述動作受限的程度，以協助醫師進行神經電生理檢查的判斷。